The relation of locomotor ataxia and paresis

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THE RELATIO

Journal for

ATAXIA AND

By J. Ramsay Hunt, M. D.,

New York,

Chief of the Neurological Clinic and Instructor in Nervous Dis-
eases in the Cornell University Medical College; Neurolo-
gist to the City and the Babies’ Hospitals.

In the whole chapter of locomotor ataxia there
is no question of greater importance than the rela-
tion which this affection bears to the general
paralysis of the insane. The importance of this re-
lation is not merely a clinical one, but has a much
deeper significance as bearing upon the underlying
nature and aetiology of the two diseases. In the
present communication there will be no discussion
of the symptomatology of tabes or of paresis. My
remarks will be confined to the combinations of the
two diseases and the nature and significance of the
so called “taboparesis.” When they occur together
is it to be regarded as a mere coincidence or com-
plication, or are the two affections essentially the
same in nature, differing only in their localization?

As is well known, tabes dorsalis is a disease char-
acterized by degenerative changes in the posterior
roots and posterior columns of the spinal cord. An
antecedent syphilis is now generally regarded as
the essential aetiological factor in the production of
this degeneration (variously estimated from fifty to
ninety per cent, of the cases). This is not syphilis
in the ordinary acceptation of the term ; but pre-
sumably a toxic state following in its wake, the so
called parasyphilis or metasyphilis.

•Discussion on Locomotor Ataxia, at the meeting of the Medical
Association of the Greater City of New York, March 16, 1908.

Copyright, 1908, by A. R. Elliott Publishing Company.

Hunt: Locomotor Ataxia and Paresis.

Paresis, on the other hand, is a degenerative af-
fection of the cerebral cortex, a degeneration of the
association and projection neurones of the brain. It
bears the same ^etiological relation to antecedent
syphilis as does tabes (according to Mendel oc-
curring in seventy-five per cent, of the cases). This
relation to syphilis constitutes an important bond of
union between these two affections, which are so
frequently found associated. Indeed, so close has
this relation appeared to Moebius that he has termed
paresis the “tabes of the brain,” and no less an au-
thority than Fournier has said of tabes that it is not
an affection of the spinal cord alone, but one of the
cerebrospinal axis.

The Combination Form of Tabes and Paresis
(Taboparesis). — The clinical course of events in the
development of taboparesis may be as follows :
Symptoms of locomotor ataxia may appear first, this
affection running its usual course, the symptoms of
paresis supervening. Such paretic indications may
develop within a few months, or may not appear
until after the lapse of many years. In rare instances
as long a period as twenty years has elapsed between
the onset of the tabes and the first symptoms of de-
mentia paralytica. On the other hand, the case may
begin as one of paresis, the tabetic symptoms devel-
oping subsequently. In not a few of the cases pare-
sis and tabes begin simultaneously and run their
course together. The importance of tabetic degen-
erations in the course of general paresis was first
pointed out by Westphal in i860. This combination,
the taboparesis, occurs so frequently that it cannot
be regarded as an accidental one, or as a mere coin-
cidence. Nageotte found that two thirds of his cases
of paresis presented symptoms of locomotor ataxia.
Shaffer found the same complication in three fourths
of his cases. Binswanger, who is somewhat stricter

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Hunt: Locomotor Ataxia and Paresis.

in his interpretation of what constitutes a tabes oc-
curring in the course of paresis, records the com-
plication in one fifth of his cases. I would empha-
size the fact that these statistics are not based upon
tabetics who were attacked with paresis, but refer to
cases of paresis in which symptoms of locomotor
ataxia are present. The proportion of cases of
tabetics developing paresis is certainly very much
smaller.

In the clinic for nervous diseases of the Cornell
University Medical College, under the direction of
Professor C. L. Dana, there have been treated dur-
ing the past six years 164 cases of locomotor ataxia ;
of this number sixteen only presented the mental or
somatic symptoms of general paresis.

Clinical Types of Taboparesis. — In order to show
the numerous varieties and manifold clinical combi-
nations which may be presented by the union of
tabes and paresis, I will mention a series of clinical
groups as outlined by Nageotte. It will be seen that
these furnish nearly every possible transition and
combination, from the simple uncomplicated tabes
to uncomplicated paresis. Simple tabes ; tabes with
slight psychical disturbances ; tabes with signs of in-
cipient paresis ; tabes with well marked paresis ; pa-
resis coming on early in tabes ; paresis beginning
with tabetic symptoms ; tabes and paresis in combi-
nation ; paresis in which the tabes appears late ; pa-
resis with only certain tabetic symptoms ; paresis
without tabetic complications.

The Pathology of Taboparesis. — The pathology of
taboparesis has been the subject of much investiga-
tion and considerable controversy. It has been held
by some that the spinal cord lesions in cases of tabo-
paresis differ from those found in simple tabes. It
is asserted that in taboparesis the endogenous degen-
erations are more numerous and occur more fre-

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Hunt: Locomotor Ataxia and Paresis.

quently than in true tabes, in which the character-
istic root and root zone degenerations are found.
While it is true that endogenous degenerations are
more frequent in taboparesis, it must be admitted
that they are also to be found in the uncomplicated
tabes, and cannot therefore be regarded as consti-
tuting an essential point of difference. Some ob-
servers have also attempted to show that the cortical
lesions of the taboparesis differ in their localization
from those of true paresis, being distributed over
the posterior and inferior convolutions of the brain
rather than over the frontal and Rolandic areas,
which is the favorite localization in true paresis.
Subsequent investigation has also disproved this, and
the tendency at the present time is to regard the
cortical changes in both affections as essentially the
same. Pathological evidence and opinion at the
present time is in favor of regarding the lesions oc-
curring in taboparesis and those occurring in simple
tabes or uncomplicated paresis as kindred in nature.

I would here mention an interesting pathological
change which is found in the cerebral cortex in some
cases of locomotor ataxia, cases which presented no
demonstrable mental symptoms during life. These
cortical alterations are histologically similar to those
found in paresis, only much milder in degree. The
existence of such alterations in the cortex of tabetics
is a further evidence of the intimate kinship existing
between the two affections. Such findings may also
be regarded as furnishing the anatomical basis for a
group of tabetic cases which present very mild symp-
toms of mental change and deterioration. In such
cases paresis may be said to be present, but in a
slumbering state. As Dejerine has expressed it,
there are many cases of tabes in which the general
paralysis remains silent.

Locomotor Ataxia and Other Psychoses. — In an

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Hunt: Locomotor Ataxia and Paresis.

affection so frequent and so widely spread as locomo-
tor ataxia, it is not surprising that there are occa-
sionally found associated with it other forms .of
mental alienation, such as paranoia, manic depressive
insanity, dementia praecox, and various mental states
following drug addictions. These cases numer-
ically are comparatively few, and it may be said
that the overwhelming majority of cases developing
serious mental symptoms fall into the group of de-
mentia paralytica.

A general idea as to the relation of tabes to insanity
other than paresis may be obtained from the com-
bined statistics of Siemerling and Moeli, who found
among 12,800 insane sixty-one tabetics. It must
also be emphasized that in the course of tabes, mild
mental states may develop upon a neurasthenic basis,
which are entirely curable, and respond readily to
proper therapeutic measures. Such cases may be the
cause of great anxiety from the resemblance which
they bear to the early stages of paresis, the so called
prseparesis. This resemblance may be so close that
the subsequent course of the case will alone furnish
a satisfactory solution of the question. It is also
well to recall in this relation the mild cortical
changes found in some cases of simple tabes without
appreciable mental changes, the silent or slumbering
paresis.

I11 conclusion, it may be said that tabes dorsalis,
dementia paralytica, and the combined form of the
two affections, all have the common etiological fac-
tor of an antecedent syphilis. The pathological al-
terations in the cerebral cortex and the spinal cord
are essentially the same in both the isolated and the
combined forms. The clinical combination of tabes
and paresis are so varied and so numerous that a
gradual transition may be traced from locomotor
ataxia, on the one hand, to general paralysis of the

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Hunt, Locomotor Ataxia and Paresis

insane on the other. In fact, it may be said that the
!-10rc °ulj kn°wledge of these parasyphilitic affec-
• n^ °f the brain and spinal cord increases the more
significant appears their combination, and the
stronger becomes the tendency to regard them all
as essentially of the same nature and origin.

1 12 West Fifty-fifth Street.

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